Provider Demographics
NPI:1386035715
Name:WILKIN, KACIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KACIE
Middle Name:
Last Name:WILKIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KACIE
Other - Middle Name:
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:527 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:KONAWA
Mailing Address - State:OK
Mailing Address - Zip Code:74849-1415
Mailing Address - Country:US
Mailing Address - Phone:580-925-3286
Mailing Address - Fax:580-925-9149
Practice Address - Street 1:905 COLONY DR
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2329
Practice Address - Country:US
Practice Address - Phone:580-436-5111
Practice Address - Fax:580-279-1994
Is Sole Proprietor?:No
Enumeration Date:2015-02-06
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2501363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2501OtherOK BOARD OF MEDICAL LICENSURE AND SUPERVISION